Medications in Schools

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Medications in Schools

• Ann Marie McCarthy, PhD, RN, FAAN
• University of Iowa, College of Nursing

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AcknowledgementsHelp from my friends

• ?Janet Williams
• ? Michael Kelly
• ? David Reed
• ? Daniel Clay
• ? Karen Farris
• ? Judith Igoe
• ? School Nurses in Iowa Nationally
• ? Nursing, Pharmacy, Education Students

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AH HA MOMENTS !

• ? Children are in Schools
• ? Health Care is
• Provided in Schools
• School Nurses
• Provide this Care

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Early School Health Projects Research

• ? School Nurse Practice (NIC)
• 2 of 3 most common nursing interventions are
  related to medications
• Pharmacy Nursing students
• Joint educational project

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Medication Management in the Schools

• What is known about medication administration in
  the school setting?
• How can we make the process safer and more
  efficient?

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Current Social Context

• Mainstreaming children with health problems
• Changing morbidities treatments
• ? Improved survival of children with complex
  health conditions
• ? Increasing use of medications for children
• ? Parents relying on schools to share
  responsibility of care

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Current Statistics

• ? 50 million children in the US in K-12
• ? 100 thousand public schools in the US
• ? 13 million children take medications in the
  USA in any 2 week time period
• ? 57 of school districts have an RN
• 35,000 school nurses
• 11,350, ratio of school nurse to students
• (1750 recommended)

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Current Systems of Authority

• ? Multiple layers
• ? Federal laws
• ? State laws
• ? Local school district
• ? Individual School
• Professional guidelines
• Educational Medical

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School Medication Management Guidelines

• ? Most include
• ? Physician order for prescription medications
• ? Written parental permission
• ? Medication at school in labeled container
• ? Stored in a secure location
• ? Written documentation

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Research on Medication Management in Schools

• Studies on
• ? School Nurses
• ? Principals
• ? Families
• ? Day Care
• ? Trends

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Study 1 Medication Administration in Schools

• ? Purpose to describe medication administration
  practices of school nurses
• ? Methods
• Design Survey, descriptive
• Subjects 649/1,000 (65), randomly selected
  from school nurses who were members of the
  National Association of School Nurses

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Results Subjects

• ? Primarily female (99.7),
• ? Middle-aged (M47.9)
• ? 23 years as an RN
• ? 11 years as a school nurse
• Education level 50 BSN,
• 22 MS/MA

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Results Medications

• Children receiving medication during a typical
  day 5.6
• ?Most common medications
• ADHD medications 3.3
• Nonprescription medications 1.5
• Asthma medications 1.1

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Results Nonprescription Medications

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Results

• ? Written guidelines 98
• Store medication in locked cabinet 80
• Self-administration allowed 76
• Secure container available for
• meds that need refrigeration 36
• Standing order for Epipens 34
• Transfer of medications 23
• Documentation of side effects 21

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Results Delegation

• ? 76 of these school nurses use UAPs to help
  dispense medications
• ? UAPs who dispense medications Secretary 66
• Health Aide 40
• Teachers 38
• Other 38
• Parents 18
• Students 16
• ? UAP education, 2 hours or less 58

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• Principal delegates medication
• administration
• in loco parentis
• School nurses comfort with UAPs
• Very/moderately comfortable 45
• Uncomfortable/very uncomfortable 33
• No response 18

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Results Errors

• ? Medication error in the last year 49
• ? Types of Errors
• Missed dose 80
• Not documented 30
• Overdose/double dose 23
• Administered, no authorization 21
• Wrong medication 20
• Contributing factors
• Use of UAP, number of children

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Conclusions

• ? Concerns with
• Delegation
• Storage of medications
• Self administration policies
• Transportation of medications/field trips
• Side effects of medications
• Nonprescription medications
• Decreasing Medication Errors

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Study 2Research with Principals
? Purpose to describe medication administration
from the principals perspective ?
Methods Design Cross sectional survey
Subjects 396/850 46.6 ? 75.5
Principals ? 16.7 School Nurses ? 7.8
Others
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Results

• ? Responsibility
• Overall School Nurse 34 Principals 41
• Daily School Nurse 76 Others 24
• ? Policies
• Pill count 22, Principals 30.6, Nurses
  15.6
• Policy for Medication on field trips
• Principals 80 School Nurses 64
  Allow Self medication 50

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Results

• ? Types of Medication Errors
• ? Missed dose medication not provided to school,
  
• ? Missed dose student did not go to the office
• ? Missed dose staff did not notify student
• ? Medication administered at wrong time
• ? Medication administered but not documented
• ?Medication administered without authorization

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Results

• ? Reasons Contributing to Medication Errors
• ? Poor communication with families
• ? Increased numbers of children on meds
• ? Poor communication with healthcare providers
• ? Increased variety of medications
• ? Staffing levels inadequate
• ? Students on similar medications
• ? Stolen medication 14-21 in middle high
  school

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Conclusions

• ? Concerns with
• Role of principal vs school nurse
• Confusion over self medication practices
• Transporting medications
• Understanding missed dose
• Factors contributing to errors
• communication and range of meds

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Study 3 Changes in Medications in Schools

• Purpose to look at the changes in medications in
  schools from 2000-2003 (post Concerta)
• ?Methods
• DesignSurvey, descriptive
• Subjects 338/1,000 (34), randomly selected
  from school nurses who were members of the
  National Association of School Nurses

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Results Prescription Medsonly 172 (50) had
data from both years
2000 Mean of Students 2003 Mean of Students
on ADHD Meds 8.7 2.7
on prescription meds 18.1 10.7
on non-prescription meds 5.9 8.0
90 of the school nurses agreed/strongly agreed that they have seen a decrease in Ritalin use 90 of the school nurses agreed/strongly agreed that they have seen a decrease in Ritalin use 90 of the school nurses agreed/strongly agreed that they have seen a decrease in Ritalin use
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Results Prescription meds

• In the late 1980s, a study
• in Illinois schools reported 58 different meds
• This study, 200 prescription medications listed
• ADHD, psych meds

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Results Non-prescription
Medication Mean of students (range)
Analgesics 6.2 (0-120)
Cough/cold 1.1 (1-40)
GI 1.2(0-52)
Alternative 0.1 (0-10)
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Schedule of administration( of nurses giving
meds at each time)
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Conclusions

• ?Decrease in number of children on ADHD
  prescription medications in schools
• ?Increase in number of children on
  nonprescription medications in schools
• ?Increase in the number range of medications in
  schools
• ?Medication administered throughout the day

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Recommendations

• Consistent guidelines
• All states/school districts require
• Safety concerns/System issues
• Delegation, storage, field trips, self
  administration, epi-pens
• ? Practice changes (2 containers,
• inhalers for school)

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Recommendations

• ?Improved communication
• Between primary provider school nurse
• Between parents school
• Between pharmacist school nurse
• Need for ongoing collaborations

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References

• Farris, KB, McCarthy, AM, Kelly, MW, Clay, D,
  Gross, J. (2003). Issues related to medication
  administration in Midwestern schools. Journal of
  School Health, 73 (9), 331-337.
• Kelly, M., McCarthy, A.M., Mordhorst, M. J.
  (2003). School nurses experiences with medication
  administration. Journal of School Nursing, 19
  (5), 281-287.
• McCarthy, AM, Kelly, MW, Reed, D (2000).
  Medication administration practices of school
  nurses. Journal of School Health, 70(9)371-376.
• Pavelka, L., McCarthy, A. M., Denehy, J.
  (1999). Use of interventions by school nurses.
  Journal of School Nursing, 15 (1), 29-37.
• Sinkovits, H.S., Kelly, M. W., Ernst, M.E. (in
  press). Medication administration in day care
  centers for children. Journal of the American
  Pharmacists Association.

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Funding

• Midwest Nursing Research Society/ Glaxo Wellcome
  Research Award
• Center for Advanced Studies Spelman Rockefeller
  (CASSPR) Grant, The University of Iowa

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Thank You!